UPMC Rehab Grand Rounds

Transcription

1 S p r i n g UPMC Rehab Grand Rounds University of Pittsburgh School of Medicine Department of Physical Medicine and Rehabilitation Pittsburgh, Pennsylvania Address correspondence to: Michael C. Munin, MD Senior Editor and Vice Chairman, Clinical Program Development Kaufmann Medical Bldg. Suite Fifth Ave. Pittsburgh, PA Telephone: Fax: Tennis Elbow: Understanding a Physiatrist s Approach to Management Megan Helen Cortazzo, MD, FAAPMR Director, Physical Medicine and Rehabilitation Outpatient Clinics Director, UPMC Mercy South Side Interventional Spine and Pain Program David M. DeChellis, DO Academic Chief Resident, Department of Physical Medicine and Rehabilitation Clinical Vignette KS is a 58-year-old female who presented to the UPMC outpatient clinic with the chief complaint of elbow pain. She reported that her job aggravated her elbow symptoms since she was employed as an attendant at a local deli. On physical exam, cervical spine and shoulder were unremarkable. Inspection of the elbow did not reveal erythema, edema, temperature changes, or muscle atrophy. She had palpatory tenderness along the lateral epicondyle and pain with wrist extension. She was diagnosed with lateral epicondyle tendinopathy. Treatment included a steroid injection and a course of physical therapy. She returned three months later with some improvement in her symptoms. Because she was responding to treatment, she received another injection, continued physical therapy, and also underwent acupuncture treatment for her pain. However, one month later she presented to the clinic with an increase in previous lateral elbow pain. MRI was ordered and demonstrated an increased signal along the attachment site of the common extensor tendon to the lateral epicondyle. The bone marrow and joint space, as well as the triceps and biceps were unremarkable. Since she was symptomatic after four months of treatment, job duty modifications were ordered, and treatment continued with acupuncture and physical therapy. In two months, her condition improved to the point that she returned to work without any job restrictions. Almost immediately, she developed an increase in her pain. She was distressed by her inability to perform all job duties, and asked if anything else could be done for her UPMC or For consults and referrals:

2 Defining the Problem Lateral epicondyle tendinopathy is a medical condition of the myotendinous junction of the wrist extensors at the lateral epicondyle, which was first described by Runge in 1873 as schreibekrampfe, which translates as writer s cramp. 1 Commonly referred to as lateral epicondylitis, this condition was described as occurring in tennis players secondary to an improper backswing. 2 The official nomenclature of this entity was declared in 1883 when it appeared in an article by H.P. Majors in The British Journal of Sports Medicine titled Lawn- Tennis Elbow. 3 The presenting symptoms for this condition typically involve the insidious onset of pain in the lateral aspect of the elbow, which may radiate distally into the forearm. Pain is often exacerbated with resisted wrist extension or repetitive wrist movements, especially with the elbow in full extension. 4 Patients also may complain of weakness in grip strength occurring with attempts to grasp or carry objects with the affected upper limb. Edema or erythema at the lateral epicondyle is uncommon, and patients typically have transient symptom relief with activity modification or relative rest of the symptomatic limb. 5 Epidemiology of Tennis Elbow The layman term tennis elbow is misleading, as only approximately 5% of cases are associated with racquet sports. 6 However, approximately 50% of tennis players will suffer from this condition at one point in their career, with a higher predilection for novice players. 7 This condition typically presents in the dominant elbow of patients who are 45 to 54 years of age, without evidence for gender preponderance. 8 The prevalence of lateral epicondyle tendinopathy is estimated to be between 1.3% to 2.8% in the general population, 8 and up to 15% in high-risk occupations that includes butchers, manual laborers, and employees in the fish processing industry. 9 High-risk occupations include ones that involve both a combination of repetitive and forceful movements of the arms. Smoking has been associated with lateral epicondyle tendinopathy. 8 The natural history of this condition is favorable, with approximately 80% of patients obtaining clinical improvement at one year from onset. 5 Pathophysiology Associated with Tennis Elbow Tennis elbow may occur as the result of a single direct trauma to the lateral elbow, however, it is more commonly reported as an overuse syndrome of the wrist extensors. 7,10 The extensor carpi radialis brevis (ECRB) is the most common muscle tendon involved with this condition, and was initially described by Cyriax in as the primary anatomic structure involved. However, in a third of cases the extensor digitorium communis also has been implicated as a source of dysfunction. 4,12 The nomenclature of this condition has frequently been considered a misnomer secondary to the actual pathophysiology. The suffix itis in lateral epicondylitis implies an inflammatory condition associated with the extensor tendons of the lateral epicondyle. Early studies by Nirschl et al showed fibroblastic invasion and vascular granulation of the ECRB, which he termed angiofibroblastic hyperplasia. 13 Further investigation into the histologic characteristics revealed collagen disorganization, mucoid degeneration, and lack of inflammatory cells. 4,13,14 Microdialysis studies of the ECRB in patients affected with tennis elbow failed to show an increase in the inflammatory mediator prostaglandin E2 compared to control subjects. 15 Since active inflammation has not been proven, the terms tendinopathy and tendinosis are now the preferred terminology. 4,10,16 Predisposing factors may include repetitive microtrauma to the common extensor tendon due to repetitive eccentric and concentric motion, in combination with poor vascularization of the proximal ECRB undersurface. 17 Pain is often the primary subjective complaint in patients with tennis elbow. The source of pain symptoms may be related to the release of neuropeptides, such as substance P and calcitonine gene-related peptides, from primary sensory nerves causing vasodilatation, plasma extravasation, and 2

3 hypersensitivity. Recent studies have shown evidence of immunoreactivity to substance P and the calcitonine gene-related peptide of sensory fibers within a subpopulation of blood vessels at the proximal tendon insertion of the ECRB. 16,18 Immunoreactivity to glutamate, a well-known modulator of pain in the central nervous system, also has been observed in the ECRB tendons in patients with tennis elbow. 19 TABLE 1: Differential Diagnosis for Lateral Epicondyle Tendinopathy Cervical radiculopathy Radial tunnel syndrome (posterior interosseous neuropathy) Supinator syndrome Dorsal antebrachial cutaneous nerve injury Radiocapetellar degeneration Proximal radial fracture Gouty arthritis Radiohumeral bursitis (Osgood s) Plica synovialis Osteochondritis dissecans of the capitellum Panner s disease (osteochondrosis of the capitellum) Radial collateral ligament pathology Proximal radial fracture Infection Examination and Diagnosis The diagnosis of tennis elbow is essentially a clinical one. After obtaining a thorough history from the patient, the physical exam should start proximally with the evaluation of the cervical spine and shoulder girdle. When evaluating the cervical spine, emphasis should be placed on excluding a radiculopathy associated with the C6 and C7 nerve roots. Shoulder instability and mechanical dysfunction also should be tested, as pathology in this region may refer pain or place inappropriate stress on the lateral elbow distally. 7 The examination should then proceed to the elbow. Limited active range of motion with wrist extension, as well as difficulty with maximal passive wrist flexion, may be noted secondary to pain at the lateral elbow. Palpation of the lateral epicondyle is often painful, with maximal point tenderness located at the lateral epicondyle or within 2 to 5 mm anterior and distal to it. 20 Tenderness at the supracondylar ridge may indicate the involvement of the extensor radialis carpi longus as well. 21 Point tenderness palpated 3 to 4 cm distal to the lateral epicondyle, or at the edge of the supinator, should make the clinician suspicious of an etiology other than tennis elbow, such as radial tunnel syndrome. 22 Provocation maneuvers also are used by most clinicians in the attempt to induce concordant pain. The tennis elbow test, also referred to as Cozen s test, is considered positive if pain occurs at the lateral epicondyle of a fully extended elbow with resisted wrist extension. 20 Another provocation maneuver, originally described to assess for radial tunnel syndrome, is the Maudsley s test. 22 Since then, it has been used by clinicians in detecting tennis elbow. This test is considered positive if pain is elicited at the lateral epicondyle of a fully extended elbow with resisted extension of the ipsilateral middle digit. 12 Although both of these provocative maneuvers are used regularly by clinicians, there is little evidence supporting their sensitivity and specificity. 20 Referred pain from shoulder pathology 3

4 Diagnostic Studies Imaging is not routinely indicated, however is obtained when lateral epicondyle tendinopathy becomes refractory, or the clinician is suspicious that another medical condition may be the source of the patient s presenting symptoms. 10 Plain radiographs of the elbow are typically negative and offer little diagnostic value for tennis elbow. Calcification along the lateral epicondyle is the most common finding associated with this condition. 23 Magnetic resonance imaging (MRI) and diagnostic ultrasonography also may be performed in selected cases to verify the suspected diagnosis, assess the degree of tendonopathy present, and identify any coexisting abnormalities. 10 MRI has superior sensitivity compared to diagnostic ultrasonography, and produces imaging features that correlate well with histologic and surgical findings. 10,14 Despite this, ultrasound (see Figure 1) still remains useful in the evaluation of lateral epicondyle tendinopathy with a sensitivity and specificity as high as 80% and 50% respectively. 10 Electrodiagnostic studies also may be used when the clinician suspects that the patient s symptoms may A Figure 1: A. Lateral epicondyle B. Extensor attachment (note hypoechoic structure) C. Joint line B C be complicated by, or stemming from, a neurological source apart from tennis elbow. Testing in this scenario will help to exclude cervical radiculopathy affecting motor fibers and screen for focal neuropathies that can mimic the condition, such as posterior interosseous neuropathy. Management of Tennis Elbow Treatment typically incorporates nonsteroidal anti-inflammatory drugs (NSAIDS) or ice, as well as ergonomic advice and modification of exacerbating activities. However, there is poor evidence supporting the use of NSAIDS or ice for this condition. 24,25 Stretching, as well as strengthening, the wrist extensors using eccentric muscle training is often prescribed due to its theorized ability to reduce strain placed on the wrist extensors through inducing hypertrophy and increasing tensile strength of the myotendinous unit. 5 However, this type of muscle training has not been shown to have significant advantage over concentric exercises or stretching alone. 26 The use of physical therapy in patients with lateral epicondyle tendinopathy can reduce time off from employment. 27 While many clinicians still consider localized corticosteroid injections a gold standard in the nonsurgical treatment of tennis elbow, there is little evidence in regard to efficacy. Injectable steroids may decrease the release of neuropeptides that have been theorized to be a source of pain in lateral epicondyle tendinopathy. One study has suggested that although superior initially, corticosteroid injections are significantly inferior in long-term follow-up to physical therapy and a wait-and-see approach. 28 The recurrence of symptoms after corticosteroid injection in long-term follow-up is quite high, and may approach up to 50% to 60%. 9,29 Topical nitroglycerin is another modality that has been used to treat this condition. It is theorized that it may help to modulate tissue healing through enhancing the production of collagen by fibroblasts. Studies have shown conflicting data regarding the effects of topical nitroglycerin when compared to physical therapy alone. 6 4

5 Many other treatment modalities have been used with the goal to alleviate symptoms and improve overall function in tennis elbow. Examples of such modalities include orthotic counterforce bracing, acupuncture, extracorporeal shock wave therapy, sclerotherapy, phonophoresis, iontophoresis, laser light therapy, and low-intensity ultrasound. Conflicting evidence exists regarding the benefits of these modalities. 5,16,30 Another relatively new treatment proposed to improve symptoms is botulinum toxin injections. Theorized to reduce stress at the extensor myotendinous junction via partial paralysis, the initial limited evidence does not strongly support use in lateral epicondyle tendinopathy. 31 Surgery is a treatment that is frequently reserved for refractory cases of tennis elbow. While open, percutaneous, and arthroscopic surgeries have all been described as approaches to this condition, little evidence is available to determine which surgical technique has superior benefit in overall outcome. Despite this fact, it is estimated that roughly 80% of patients have a successful outcome regardless of surgical technique used. 32 Although a large amount of anecdotal success has been reported, there is poor consensus supporting standardized treatment based on the scientific literature. The analysis of randomized clinical trials for the treatment of lateral epicondylitis frequently reveals significant methodology flaws, and there is a low level of evidence for current interventions. 33 New Treatment: Autologous Platelet-Rich Plasma In the search for better treatment of tennis elbow, platelet-rich plasma (PRP) has gained popularity with musculoskeletal medicine physicians. Although highly debated, PRP, by its strictest definition, is an autologous sample of blood with a concentration of platelets above the physiologic baseline. The concept behind its use in nonsurgical musculoskeletal medicine is to inject areas of soft tissue pathology via percutaneous injection in order to facilitate tissue healing. This healing is theorized to occur secondary to the PRP s ability to promote recruitment, proliferation, and differentiation of cells involved in tissue regeneration. 34,35 In order for platelets to influence tissue healing, activation is first required. This occurs through an external source, at which time platelets alter their morphological structure in a process known as degranulation. Some clinicians choose to activate the PRP prior to injection using a variety of sources, while others allow platelets to become activated in vivo through the interaction with type I collagen. 36 During this process platelets release up to 95% of their presynthesized growth factors and bioactive molecules from granules within the first hour after activation. These growth factors and molecules then induce advantageous changes within the healing cascade. 34,35 In regards to PRP in the treatment of tennis elbow, early anecdotal and case study reports have been encouraging. A small cohort study by Mirsha et al in 2006 showed an improvement of pain and overall function in patients treated with PRP compared to controls. 37 A more recent randomized controlled study by Peerbooms et al compared local PRP injection to local corticosteroid injection in patients with clinical evidence of chronic tennis elbow refractory to prior treatments. 37 Fifty-one patients were randomized to receive PRP injection, while 49 patients were randomized to receive corticosteriod injection. Successful treatment was defined as an improvement of 25% in a visual analog score (VAS) or Disability of the Arm, Shoulder, and Hand (DASH) Outcome Measure score without a reintervention after one year. Data showed significant differences between treatment groups. Specifically, 73% of patients in the PRP group compared to 49% of patients in the corticosteroid group had succesful outcomes in VAS score (p <.001), while 73% of patients in the PRP group compared to 51% of patients were successful in the DASH score (p =.005). 38 Whole blood (rather than just injecting platelets) has been used in recent years to treat lateral epicondyle tendinopathy based on theoretical benefits that include bringing endogenous cellular and humoral 5

6 mediators within blood to augment healing. 29 Kazemi showed a statistically significant difference in pain and overall function in favor of patients receiving whole blood injection into the tendon compared to localized corticosteroid injection at four and eight weeks. 29 Clinical Vignette Summary A B We offered KS the treatment option of platelet rich plasma for her chronic lateral epicondyle tendinopathy. We discussed the theoretical benefits, as well as current literature-supported evidence, with the patient in detail. KS elected to have the procedure based on the refractory nature and duration of her symptoms. Upon ultrasonographic evaluation of her lateral epicondyle (see Figure 1), it was evident that the common extensor tendon was hypoechoic, signifying chronic degenerative changes in the tendon. After informed consent was obtained, 60 milliliters of the patient s blood was withdrawn and placed into a centrifuge system. Then 3 ml of platelet rich plasma was extracted for injection after the area was cleansed in an aseptic fashion. The skin overlying the injection site at the lateral epicondyle was anesthetized. The PRP solution was not activated prior to injection in order to allow this to occur in vivo after contact with the collagen associated with the wrist extensor tendon. Using ultrasound guidance (see Figure 2), Figure 2: A. Lateral epicondyle and wrist extensor attachment B. Needle the needle was advanced towards the proximal attachment of the common extensor tendon, as well as the hypoechoic regions. A total of 1.5 ml of platelet rich plasma was injected after percutaneous tenotomy was performed. KS stated that the injection was uncomfortable. At follow-up eight weeks after her treatment, the patient reported complete resolution of her symptoms and was working full time at her deli in an unrestricted fashion. 6

8 No-Fee CME UPMC is proud to be a resource for physicians across the country and around the world. Our commitment to CME is demonstrated here by offering CME credit free of charge for Rehab Grand Rounds. To receive CME credit for this piece, follow these easy steps: 1. Go to https://cme.hs.pitt.edu. 2. If you re a first-time user, you will need to create an account by going to Create Account on the right-hand side of the screen. Returning users will enter an address and password after clicking on Login. 3. Once logged into the system, you can browse modules by selecting the UPMC Department of Physical Medicine and Rehabilitation-Grand Rounds folder then scrolling down to PMR Spring After selecting a module, you can read about the module through the Content Header and then either click Next Step or use the Step by Step box. 5. The Step by Step box will guide you through the educational portion, quiz, evaluation, and certificate steps. 6. Please allow one business day for credit transcript. To print or view your transcripts, visit https://ccehs.upmc.com. On the left side of the page, click Credit Transcripts. The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The University of Pittsburgh School of Medicine designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. Each physician should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded (0.1) continuing education units (CEU) which are equivalent to 1.0 contact hours. UPMC Department of Physical Medicine and Rehabilitation UPMC is ranked by U.S. News & World Report as one of the top hospitals in the country for rehabilitation. The Department of Physical Medicine and Rehabilitation is a top recipient for NIH funding for rehabilitation-related research. The Spinal Cord Injury Program at UPMC is one of only 14 in the country selected by the National Institute on Disability and Rehabilitation Research as a model for other rehab providers. Department clinicians lead UPMC s rehabilitation network of more than 70 inpatient, outpatient, and long-term care facilities one of the country s largest. To learn more about how UPMC is transforming physical medicine and rehabilitation, go to or UPMC is an $8 billion global health enterprise with almost 50,000 employees headquartered in Pittsburgh, Pa., and is transforming health care by integrating 20 hospitals, 400 doctors offices and outpatient sites, a health insurance services division, and international and commercial services. Affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC is redefining health care by using innovative science, technology, and medicine to invent new models of accountable, cost-efficient, and patient-centered care. For more information on how UPMC is taking medicine from where it is to where it needs to be, go to UPMC.com. UPMC is an equal opportunity employer. UPMC policy prohibits discrimination or harassment on the basis of race, color, religion, ancestry, national origin, age, sex, genetics, sexual orientation, marital status, familial status, disability, veteran status, or any other legally protected group status. Further, UPMC will continue to support and promote equal employment opportunity, human dignity, and racial, ethnic, and cultural diversity. This policy applies to admissions, employment, and access to and treatment in UPMC programs and activities. This commitment is made by UPMC in accordance with federal, state, and/or local laws and regulations. USNW Q/LG 3/11

UNC SPORTS MEDICINE FAMILY MEDICINE Lateral Epicondylitis What is lateral epicondylitis? Lateral epicondylitis, or tennis elbow, affects 1-3% of Americans each year. The epicondyles are the two bumps on

Tennis Elbow (Lateral Epicondylitis) Page ( 1 ) Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can

Originally described in Lancet, 1882 as Lawn Tennis Arm. 10-50% of tennis players will suffer from lateral epicondylitis Tennis players account for less than 5% of overall cases Common in construction,

Tennis Elbow (Lateral Epicondylitis) Page ( 1 ) Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can

Tennis Elbow (Lateral Epicondylitis) Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can cause this

Gx Are you suffering From Lateral Elbow Pain? It may be Tennis Elbow It is a common condition of Elbow due to overuse of muscles & tendons around elbow. Then GO FOR PRP (PLATELET RICH PLASMA) THE NATURAL

BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology UPPER EXTREMITY ASSESSMENT MSAK201-II Session 8 LEARNING OBJECTIVES: By the end of this session, the

Temple Physical Therapy A General Overview of Common Neck Injuries For current information on Temple Physical Therapy related news and for a healthy and safe return to work, sport and recreation Like Us

MRI for cervical radiculopathy Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected: cervical radiculopathy

Rotator Cuff Tears Description Rotator cuff tear is a common cause of pain and disability in the adult population. The rotator cuff is made up of four muscles and their tendons. These combine to form a

Copyright 2009 American Academy of Orthopaedic Surgeons Cervical Spondylosis (Arthritis of the Neck) Neck pain is extremely common. It can be caused by many things, and is most often related to getting

Exercise Away Your Knee Pain It seems counterintuitive, but when it hurts to move your knee, the best thing you can do is move your knee. A 2009 study in the British Medical Journal found that supervised

Rotator Cuff Tears Page ( 1 ) A rotator cuff tear is a common cause of pain and disability among adults. In 2008, close to 2 million people in the United States went to their doctors because of a rotator

Rotator Cuff Tears Description Rotator cuff tears are a common cause of pain and disability in the adult population. The rotator cuff is made up of four muscles and their tendons. These combine to form

DEFINITION A syndrome of hand and wrist numbness and/or paresthesia due to entrapment of the median nerve as it passes through the carpal tunnel from the wrist to the hand. ISSUES CTS has an indistinct,

Short Question: Specific Question: In patients presenting with acute or chronic tendinopathies, what is the incidence of harm for those receiving steroid injections compared to those receiving usual care?

High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty

Treatment Guide Understanding Elbow Pain Elbow pain is extremely common whether due to aging, overuse, trauma or a sports injury. When elbow pain interferes with carrying the groceries, participating in

Low Back Injury in the Industrial Athlete: An Anatomic Approach Earl J. Craig, M.D. Assistant Professor Indiana University School of Medicine Department of Physical Medicine and Rehabilitation Epidemiology

NAJSPT CLINICAL SUGGESTION A NEW EXERCISE FOR TENNIS ELBOW THAT WORKS! Phil Page, PT, PhD, ATC, CSCS 1 ABSTRACT Eccentric exercise has been effectively used in the management of tendinopathies in multiple

OXFORD SHOULDER & ELBOW CLINIC INFORMATION FOR YOU Tennis Elbow or Lateral Epicondylitis The aim of this information sheet is to give you some understanding of the problems you may have with your elbow.

CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF LOW BACK PAIN Low back pain is very common, up to 90+% of people are affected by back pain at some time in their lives. Most often back pain is benign and

Neck Injuries and Disorders Introduction Any part of your neck can be affected by neck problems. These affect the muscles, bones, joints, tendons, ligaments or nerves in the neck. There are many common

Learn the anatomy of the foot. Identify key terms associated with plantar fasciitis. Determine the causes of plantar fasciitis and understand why it occurs. Recognize the injury when it occurs and be able

Cervical Spondylosis (Arthritis of the Neck) Page ( 1 ) Neck pain can be caused by many things but is most often related to getting older. Like the rest of the body, the disks and joints in the neck (cervical

1 of 6 1/22/2015 10:06 AM 2 of 6 1/22/2015 10:06 AM This cross-section view of the shoulder socket shows a typical SLAP tear. Injuries to the superior labrum can be caused by acute trauma or by repetitive

Chronic Low Back Pain North American Spine Society Public Education Series What is Chronic Pain? Low back pain is considered to be chronic if it has been present for longer than three months. Chronic low

Copyright 2011 American Academy of Orthopaedic Surgeons Shoulder Impingement/Rotator Cuff Tendinitis One of the most common physical complaints is shoulder pain. Your shoulder is made up of several joints

05/05/2007 INJURIES OF THE HAND AND WRIST By Derya Dincer, M.D. Hand injuries, especially the fractures of metacarpals and phalanges, are the most common fractures in the skeletal system. Hand injuries

www.noc.nhs.uk Achilles Tendinopathy: Advice and Management Delivering Excellence oxsport@noc Department of Sport and Exercise Medicine Are we speaking your language? If you would like information in another

THE WRIST At a glance The wrist is possibly the most important of all joints in everyday and professional life. It is under strain not only in many blue collar trades, but also in sports and is therefore

C H A P T E R 2 1 DISORDERS OF THE ACHILLES TENDON William D. Fishco, DPM A common podiatric complaint is pain in the region of the Achilles tendon. A careful examination and history taking helps decipher

Is day or night time splinting more effective than usual care in improving pain, function and reducing sensory disturbance in adults with Carpal Tunnel symptoms? Clinical Bottom Line Splinting can be beneficial

Total Elbow Arthroplasty and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: There are three bones and four joint articulations that have a high degree of congruence in

A Patient s Guide to Quadriceps Tendonitis 2350 Royal Boulevard Suite 200 Elgin, IL 60123 Phone: 847.931.5300 Fax: 847.931.9072 DISCLAIMER: The information in this booklet is compiled from a variety of

Shoulder Pain and Common Shoulder Problems Page ( 1 ) What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm from scratching

Page 1 of 6 Scaphoid Fracture of the Wrist Doctors commonly diagnose a sprained wrist after a patient falls on an outstretched hand. However, if pain and swelling don't go away, doctors become suspicious

Bursitis and tendinitis are both common conditions that cause swelling around muscles and bones. They occur most often in the shoulder, elbow, wrist, hip, knee, or ankle. A bursa is a small, fluid-filled

below the patella. The tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon

Doctor of Science in Physical Therapy The mission for the Doctor of Science (Sc.D.) Program in Physical Therapy is to provide advanced post-professional education to practicing physical therapists in Texas

INSERTIONAL TENDINOPATHY OF THE ACHILLES TENDON Heel pain is a common complaint and is often poorly managed. Non-operative treatments are highly effective for the vast majority of patients, and surgery

Rotator Cuff Injury and Pathology The rotator cuff is made up of four muscles - supraspinatus, infraspinatus, subscapularis and teres minor. The tendons of these muscles blend together to form a cuff around

Herniated Cervical Disc North American Spine Society Public Education Series What Is a Herniated Disc? The backbone, or spine, is composed of a series of connected bones called vertebrae. The vertebrae

ELBOW EXAMINATION What s the problem Pain Instability Stiffness Disability Which hand? How old? Occupation Any history of injury Assess disability Work and ADL 1. Can you lift heavy weights? 2. Can you

Whiplash Associated Disorder Bourassa & Associates Rehabilitation Centre What is Whiplash? Whiplash is a non-medical term used to describe neck pain following hyperflexion or hyperextension of the tissues